This application for a Midcareer Investigator Award in Patient-Oriented Research (K24) requests PI salary and research funds to support Dr. Happ's research to improve care and communication with nonspeaking ICU patients and extend her research mentorship opportunities through two new research projects that explore Symptom Management, Patient-Caregiver Communication, and Clinical Outcomes. Using an adaptation of the Revised Symptom Management Model (Dodd et al., 2001) and building on data from an existing R01 clinical trial, Project 1 will examine relationships between nurse-patient communication performance (difficulty, quality, successfulness), symptom management (symptom experience and treatment), and clinical outcome variables (ventilator-free days, length of ICU stay, hospital LOS). Project 2 will describe (1) families' perceptions of patient communication difficulty during critical illness, (2) families' involvement with assisted communication strategies, and (3) patient-family communication performance when ICU patients receive an assistive communication device and/or speech language pathologist (AAC- SLP) consultation intervention. In addition to advancing Dr. Happ's skill in symptom and outcome measurement in critical illness, this award will help develop an intervention to improve family caregivers' communication with ICU patients who are unable to speak. Testing associations between communication performance and symptom management will provide a theoretical structure for future biobehavioral research in critical illness. Investigator development will include consultation and training experiences with multi-site investigators and experts in symptom measurement with nonspeaking ICU patients well as attendance at the NIH Summer Institute in Clinical Trials Research. The Midcareer Investigator Award will provide protected time and additional opportunities to mentor undergraduate, graduate students and interdisciplinary junior faculty in theory building research, observational research techniques, and intervention development and testing. This award will also facilitate the interdisciplinary team building necessary to conduct a multi-site RCT. The proposed work is relevant to NINR's strategic mission in several ways: (1) improve recognition and management of symptoms by caregivers and health care providers; (2) develop interventions to improve the quality of caregiving, specifically nurse and family bedside caregiving in the ICU. [unreadable] [unreadable] [unreadable]